Paradigms in Liver Surgery: Conserve as much normal liver as possible

The key to successful liver surgery is to preserve as much of uninvolved liver as possible. This is very important when the patient has liver fibrosis or cirrhosis, which can fail after liver resection. In our institute, we use the following methods to assess how much of liver we are going to resect and preserve.

We look for features of liver disease in your labs: Platelet counts, bilirubin, albumin and the AG ratio. Low platelet counts, low albumin and low AG ratio and high bilirubin will indicate that the patient may not tolerate a large volume resection.

We look for indirect signs of portal hypertension in the Doppler ultra-sonogram and also in the endoscopy. The presence of clinically overt portal hypertension may contraindicate every type of liver resection and tilt care towards transplantation.

We biopsy the uninvolved liver in case of doubt and assess the actual disease severity under the microscope.

Right anterior sector resection for hepatocellular carcinoma done by me in a 67 year old gentleman with fibrosis of remaining part of the liver. This increases the chance of liver failure and we preserved as much liver as possible without compromising the cancer clearance. He was discharged on post operative day 7.

With cirrhosis, we can resect up to a maximum of 2 segments of the liver. We try to reduce the liver mass to be resected by using portal vein embolization and causing hypertrophy or enlargement of the lobe that is going to be left behind. It also serves as a test for the ability of the liver too grow after resection.

Bisegementectomy is removal of two contiguous segments of the liver is a good technique to preserve as much liver as possible. Removal of perpendicularly oriented liver segments with removal of an entire portal feeding area is one of the challenging operations. Orderly resection of the liver with preservation of flow to the adjacent sectors and the biliary drainage is a skill that should not be under estimated.

Keeping the right plane of dividing the liver and ensuring good margins from the tumour is a skill that one takes a while to master. We also found that our skill in performing ultrasound on the liver to guide our surgery is a big plus in handling larger liver tumours. This enables us to precisely place the plane along the blood vessels and also plan good margin all around the tumour.

In operating on these patients, we learnt that the most successful procedures use patient management skills that one learns in liver transplant, especially in the management of living donor liver transplant patients. The surgeon needs to be proficient in the management of liver dysfunction and derangements that happen with these surgeries.

A good interventional radiology support also ensures that we can take more bolder steps to treat minor complications.

I have always felt that the best way to treat liver tumours is not to take more, but to leave more and take as much as is needed for good results. Maximal conservation of uninvolved livers is the key to successful liver surgery in these days of obesity, fatty liver and fibrotic livers.